Grands rounds in the age of COVID-19; cardiotoxicity in breast cancer

Thursday, March 26, 2020

Susan Dent, MD, codirector of the cardio-oncology program at Duke University in Durham, N.C., reflects on virtual grand rounds, telehealth, the screening of patients before clinic visits, and other new realities of cancer care in the age of COVID-19. Dr. Dent also discusses the importance of assessing breast cancer patients for cardiotoxicity.

In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the importance of advance directives.

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Cardiotoxicity in breast cancer treatment

HER2 drugs (such as trastuzumab) and conjugates

  • If given appropriately, these drugs have limited cardiotoxicity.
  • The mechanism of cardiotoxicity is a “stunning of the heart.”
  • If there is a significant drop in left ventricular ejection fraction (LVEF), you may need to hold the drug but this should be restarted if LVEF improves.
  • When problems arise, they tend to occur early on.
  • Important to assess baseline risk factors. Older individuals with underlying hypertension, diabetes, and other conditions need monitoring.

Anthracyclines

  • The appropriate/safe dose of anthracyclines may be different for each person, based on risk factors such as age and underlying conditions.
  • Assess patients at baseline using cardiac imaging and biomarkers, and risk factors. If no symptoms of cardiotoxicity, reassess 6-12 months after treatment.
  • If a patient has poorly controlled hypertension or diabetes, those factors should be better managed to minimize the risk from anthracyclines.

Liposomal anthracyclines

  • These formulations are less cardiotoxic, but they have not been widely adopted in breast cancer.

Immuno-oncology antibodies

  • Myocarditis is one of many side effects seen with immunotherapy. It’s not a common side effect (about 1% or less), but when it does occur, it has a 50% fatality rate. Have a high level of suspicion for myocarditis if a patient on immunotherapy presents with shortness of breath and chest pain.

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Ilana Yurkiewicz on Twitter: @ilanayurkiewicz

Podcast Participants

David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd.
Ilana Yurkiewicz, MD
Ilana Yurkiewicz, MD, is a fellow in hematology and oncology at Stanford University, where she also completed her internal medicine residency. Dr. Yurkiewicz holds an MD from Harvard Medical School and a BS from Yale University. She went into hematology and oncology because of the high-stakes decision-making, meaningful relationships with patients, and opportunity to help people through some of the toughest challenges of their lives. Dr. Yurkiewicz is also a medical journalist. She is a former AAAS Mass Media Fellow and Scientific American blog columnist, and her writing has appeared in numerous media outlets including Hematology News, where she writes the monthly column Hard Questions. Dr. Yurkiewicz is on Twitter: @ilanayurkiewicz.